1. Technical Field of the Invention
The present invention relates generally to database and file management or data structures. Specifically, it provides a system and method for creating global rules that reduce data redundancy and computational latency by consolidating duplicated payor rules.
2. Description of Related Art
Medical practices treat thousands of patients, insured by various healthcare organizations. As a result, a critical daily component of the Practitioner's organization involves the successful processing and filing of medical claims to a multitude of payors. While there is considerable commonality in claim information between payors, each payor can have differing rules regarding the claim format and content, further increasing the complexity of the processing and filing.
Practice Management Software (PM) is the most common way medical providers submit insurance claims. Many PMs have claim scrubbing features that review claims for inaccuracies prior to submission. However, despite scrubbing efforts to increase successful processing, human error is unavoidable. A common reason for errors is differences between submission requirements among payors. Although some submission requirements apply to all payor organizations (i.e. universal rules), currently used PMs also separately collect and store unique payor rules needed for claim submission compliance. To ensure compliance with all the rules, universal or unique, Practitioners must manually apply the rules for each payor organization—directly reducing available time and resources for seeing patients and earning revenue.
Storing, maintaining, and processing numerous redundant payor rules makes PM software setup very resource intensive. Large amounts of network resources are spent storing and processing superfluous payor rules, thereby causing data clutter. The PM software setup process is further affected due to unnecessary setup protocols that force medical practices to communicate with setup systems. The added inefficiency of data clutter and additional setup protocols cause implementation errors and resource drain, further reducing medical organizations' ability to realize improved data interoperability via collaboration.
The St. Claire, et al. patent application; having U.S. patent application Ser. No. 11/493,922; filed Jul. 27, 2006; and entitled, “System and Method for Health Care Data Integration and Management”; discloses one attempt to eliminate redundant data by focusing on combining duplicate data allocated among distinct medical organizations. The method comprises gathering all data from participating organizations and compiling the data into a conglomerate group. This allows any overlapping data to be identified and permanently eliminated. Then, once the redundant data is removed, the remaining data is re-categorized and disseminated for utilization. However, despite this system and method's efficacy in data reduction among shared communications, the underlying latency issues from resource drain remain unresolved. Eliminating partial data does not address core issues in computational latency. Re-categorizing existing data may reduce clutter, but it has no bearing on expediting automated form completion.
The Kay patent; having U.S. Pat. No. 7,630,911; filed Oct. 23, 2002; and entitled, “Method of Automated Processing of Medical Data for Insurance and Disability Determinations”; discloses another method for the elimination of redundant data during preliminary health insurance vetting methods. The method suggests patients seeking special medical coverage must complete medical claims that declare patients' ailments and/or symptoms. This often results in multiple claims per patient being filed—each claim represents a respective ailment. Medical practitioners must administer specific protocols for each claim, often causing an overlap in the implementation of services. In order to reduce the overlap, the method involves creation of primary databases that encompass explanations for all claim types. An auxiliary database acts as a liaison between the primary database and medical practitioners, providing Practitioners with detailed explanations for non-overlapping administration of services in response to multiple claims. This system does reduce the administration of overlapping medical services, but it perpetuates redundant data computation and introduces additional latency issues inherent in the maintenance of multiple synchronized databases.
The Christen patent; having U.S. Pat. No. 7,970,629; filed Oct. 19, 2007; and entitled, “Adaptive System for Financial Claim Reimbursement Processing”; discloses yet another system attempt to expedite medical claim submissions by reorganizing payor rules to accommodate medical practices' claim submission workflow. In short, medical claims are invoices addressed to insurance payors for compensation for administered medical services and/or goods. Often, distinct payors require unique claim submission compliance, thereby requiring storing and maintaining myriads of data. To alleviate the strain of maintaining copious amounts of data, the system reorganizes the stored rules according to importance and frequency of use with certain claim types. This system addresses the redundant data computation and additional latency issues the prior system discussed, but it does not optimize potential benefits. Simply reallocating payor rules among different data tables produces minimal results because the system still must cipher through myriads of data regardless of relocation.
The Petito at al. patent application; having U.S. patent application Ser. No. 10/664,486; filed Sep. 17, 2003; and entitled, “Automated Work-Flow Management System with Dynamic Interface”; discloses a further system that focuses on eliminating the inputting of redundant data during the automated creation of electronic forms, which are used to communicate among parties despite geographical separation. In this system, users are issued electronic cards (ecards) that are displayed on the input interface and communicate with databases that store algorithms/rules. Ecards provide the system with the data needed for the creation of forms and upon receipt and the algorithms are used to populate the forms. This invention reduces data redundancy; however, it does not reduce the pervasive latency issues caused by excessive data storage. Even though this system does not call for the redundant data to be appended onto the forms, it still requires valuable system resources to be spent housing, processing and managing superfluous data.
The Amar et al. patent; having U.S. Pat. No. 7,617,116; filed Aug. 3, 2001; and entitled, “Practice Management and Billing Automation System”; discloses an additional system that attempts to address problems with PM setup and claim submission protocols. This system's PM setup process includes a setup server that communicates with medical practices and relevant payors. The setup server requests initial setup information such as address, physicians' names, and accepted insurance payors from medical practices. Next, the setup server uses the data provided to begin the PM setup, including retrieving payor rules needed for claim submissions. Insurance payors often require compliance with relative standards during claim submission, thereby requiring subsequent data from medical practices to satisfy compliance. Ideally, the system's setup process would only require a maximum of two data requests; however, unforeseen rules collection issues may easily require additional requests. The likelihood for additional required requests introduces inefficiency into the PM setup process due to excessive communications between parties. Also, this invention's claim submission process lacks efficiency due to inadequate housing and implementation of insurance payor rules. The system creates multiple database tables and each table is utilized specifically to store all rules relating to one payor. Again, even though many rules are commonly shared among payors, the system teaches database storage of duplicate rules, thereby fostering redundancy and computational latency. The system attempts to mitigate this latency by recognizing and partially eliminating redundant rules within individual payor tables that have similar end results. Few redundant rules are actually eliminated though, leaving behind redundant rules related to each payor.
In light of the current state of the art, it is readily apparent that a comprehensive solution to inefficient data processing is needed. Reorganizing, renaming and/or relocating redundant data may provide temporary solutions to part of the problem; however such processes do not optimize database resources that facilitate efficient claim submissions. Thus, there is a need for a system and method of effectively analyzing payor rules to consolidate duplicate rules into new “global” rules, which remove the superfluous data from the database and reduce computational latency.